OPIOID IN ALZHEIMER’S DISEASE 1ARTICLE CRITIQUE 9Opi.docx

OPIOID IN ALZHEIMER’S DISEASE
1
ARTICLE CRITIQUE
9
Opioid use and the presence of Alzheimer's disease and related
dementias among elderly Medicare beneficiaries diagnosed with
chronic pain conditions
Chan Shen, Xiaohui Zhao, Nilanjana Dwibedi, R. Constance
Wiener, Patricia A. Findley & Usha Sambamoorthi
Odanayza Casanola Chavez
Article title: Opioid use and the presence of Alzheimer's
disease and related dementias among elderly Medicare
beneficiaries diagnosed with chronic pain conditions
Authors: Chan Shen, Xiaohui Zhao, Nilanjana Dwibedi, R.
Constance Wiener, Patricia A. Findley & Usha Sambamoorthi
Introduction
Summary: The study by Shen et al. (2018) represents a
retrospective-cross-sectional study which aimed at determining
the relationship between ADRD (Alzheimer's disease and
related dementias) and opioids prescription among elderly
patients as compared to their counterparts without ADRD.
Through the use of Medicare beneficiaries from 2006 to 2013,
the study was able to determine the fact that opioids
prescription among elderly patients with ADRD is
comparatively lower than their non-ADRD counterparts hence
leading to possibly unmet pain management needs for elderly
patients with ADRD. This trend is largely caused by the
unfounded notion that opioids use have negative effects among
ADRD patients in as far as worsening ADRD symptoms is
concerned.

Problem: The fundamental problem that informed this study has
been clearly stated. Arguably, the problem is quite practical
owing to the fact that pain is a major cause of low quality of
life among elderly persons. There have been a lot of fears
associated with opioids use among elderly patients with ADRD
due to the assumptions that opioids may exacerbate ADRD
symptoms. Although opioids have been evidently associated
with major pain relief capabilities- their use among ADRD
patients experiencing pain is minimal. Therefore, the authors
hypothesize that there is great risk of going with unmet pain
management needs among elderly persons with ADRD as
compared to their counterparts without ADRD.
While the research questions have not been explicitly
highlighted, it is apparent that as can be extrapolated from the
research aims- the primary research questions that the study
pursued to answer relates to whether opioids use in elderly
patients is in any way linked to increased risk of ADRD and
whether elderly patients with ADRD are more likely to endure
sub-optimal pain management due to limited prescription of
opioids. The researchers utilized a sample of n= 19,347
participants who were Medicare beneficiaries between 2006 and
2013. Among these participants, 7.7% of them had ADRD and
the rest were ADRD-free. By analyzing opioids prescription for
this period, the study found out that participants with ADRD
received less opioids prescriptions as compare to their non-
ADRD counterparts therefore confirming that community-
dwelling elderly patients with ADRD are more likely to
experience unmet pain management needs. In addition to that,
the key terms have been clearly highlighted and defined.
Evaluation of research methods
Does the author provide a literature review?
Although there is no particular section that has been purely
focused on literature review, it is apparent that a comprehensive
review of literature has been conducted especially in the

description of the background of the study. The ultimate
purpose of a literature review is to retrieve any related research
information that has been published in relation to a research
topic (Ellis, 2019). This serves the purpose of validating the
research based on an identified gap. This is something that the
study has appreciably done and there is sufficient utilization of
existing literature not only to show case the existing
information about the topic but also to validate the need for
research enquiry on the area of opioids prescription among
elderly patients with ADRD.
Is the research current and relevant to today existing health
issues?
The sources of literature that have been used include systematic
reviews, quantitative studies and qualitative studies on this
topic. These use of these literature sources means that the
literature is based on best sources of evidence (LoBiondo-Wood
& Haber, 2017). In addition to that, the sources of the literature
fall within the last one decade prior to the publication of the
study. This means that the research is current and tuned with the
present-day healthcare practice in as far as opioids use is
concerned. Arguably, use of recent and up-to-date literature
translates to increased credibility and sound understanding of a
research issue under enquiry and that the knowledge utilized is
tuned with the current research knowledge.
Describe the research type utilized? – Experimental, non-
experimental, quasi experimental, etc.
The research is non-experimental in nature since there are no
causal relationships being established. In this connection, the
study can be termed as largely explorative or descriptive in
nature since it uses published data on opioids use to describe
trends and patterns of opioids prescription among elderly
patients with ADRD as compared to elderly patients without
ADRD.
Evaluate the sample (size, composition, or in the way the

sample was selected in relation to the purpose of the study? Was
the sample appropriate for the research or was it bias?
The sample size of any study goes a long way when it comes to
influencing the generalizability of research findings. A good
sample should be able to represent the larger sample of
population under study in terms of age, gender and other
pertinent demographic characteristics (Dale, Hallas & Spratling,
2019). The sample size in this study is large and sufficient to
paint a clear picture of the issue being investigated. The use of
this sample size enhances the accuracy and generalizability of
research findings in multiple care settings or scenario. The
sample is well represented in terms of gender and there is an
even distribution of people from all socio-economic and literacy
levels. In addition to that, the sample was inclusive enough
since information had been retrospectively retrieved from
factual clinical data between 2006 and 2013. In this regard this
prevents any room for bias in as far as sample selection is
concerned.
How practical does this work seem to you? How does the author
suggest research results could be applied and how do you
believe they could be applied?
This work and the subsequent findings are quite practical.
Arguably, pain is a major impediment towards enjoying a high
quality of life for elderly patients. The exclusive or somewhat
discriminatory use of opioids for certain elderly populations
such as those with ADRD is not warranted and leaves them
enduring pain due to denied access to opioids for pain
management. There is no scientific evidence that links ADRD
with opioids and for that reason- healthcare professionals seem
to prescribe opioids based on personal persuasions and
unfounded evidence. The authors therefore suggest that real life
practice should embrace use of opioids for all patient
populations including those with ADRD so as to enhance
quality of life through effective pain management. However, it

is important to acknowledge that the use of opioids should be
done in line with existing guidelines and practice protocols in
order to prevent the possible scenario of addiction.
Could the study have been improved in your opinion? If so
provide how you think it could have improved.
Definitely, the study could have been improved since the issue
of opioids use among elderly patients present different facets.
The study could thus be improved through incorporating views
from elderly patients on opioids for pain management as well as
the views of healthcare professionals about their attitudes about
opioids use among elderly patients with ADRD. This could have
fostered a holistic understanding of the research issue from
different perspectives other than clinical data. In this regard,
this improvement could have been made through the use of a
mixed approach that utilizes both quantifiable clinical data
relating to opioids use as well as a qualitative approach that
seeks to understand different opinions surrounding opioids use
for the study population.
Is the writing in the article clear straightforward?
The article has been written clearly and concisely making it
easy for the reader to go through the entire piece without
encountering an area of ambiguity. To aid in reading and
understanding the research article, the authors have gone an
extra mile to define complex terms. In addition to that, there is
smooth transition from one section to the other or from one idea
to the next hence making it easy to follow through the entire
article effectively.
Can further research be conducted on this subject? Explain
It is apparent that opioids use among the elderly patients may be
associated with various behavioral problems such as addiction.
The use of opioids for management should be done in the most
cautious manner to prevent these negative effects. In this
regard, future research can be done on characterization of pain

in terms of pain intensity and duration and subsequently assist
in providing guidelines on which pain characteristics qualify for
opioids prescription. Finally, future research can also focus on
coming up with factual evidence-based guidelines that can be
used to come up with noble prescription opioids practices. It is
through such an approach that the larger healthcare system can
strike a healthy balance between the pain management needs of
elderly persons and the need to shelter elderly persons from
various possible behavioral and psychological effects of
opioids.
Conclusion
In conclusion it is apparent that opioids use for pain
management among elderly patients with chronic pain has been
an area of much scholarly and scientific debate. Some quotas
hypothesize that opioids increase the risk of dementia or
Alzheimer’s among this patient population. Nevertheless, there
is no tangible scientific evidence that supports this claim. Such
notions have led to decreased use of opioids among elderly
patients with chronic pain due to the dementia-related fear. To a
large extent, this leaves many elderly patients enduring chronic
pain with potential unmet or sub-optimally met pain
management needs. In this regard, the findings of this study are
of great significance and ought to influence future practice and
other similar research undertakings. Old age and frailty attract a
myriad of physiological alterations that can hamper the quality
of life of elderly persons. For instance, this group of patients
experience age-related conditions such as osteoporosis,
osteoarthritis, musculoskeletal pains and different forms of
cancer.
All these conditions are characterized by severe levels of pain
that compromise quality of life and hence lead to impaired
uptake of daily living activities and independence (Wang, Hill,
Gomes, Pinto, Wijeysundera, Scales & Wunsch, 2020). Opioids
have been evidently associated with significant positive effects
in as far as pain management is concerned. Therefore, it is not
logical to withhold prescription of opioids for elderly persons

due to the unfounded fear of the link between opioids and
dementia/Alzheimer’s. Nevertheless, there is the need to
acknowledge that long-term use of opioids may attract
behavioral problems such as addictions and hence the need to
use the currently existing standards on opioids prescription so
as to shelter elderly patients from the risk of addiction of
opioids dependence (Wang, Hill, Gomes, Pinto, Wijeysundera,
Scales & Wunsch, 2020). For instance, there is the accentuation
to monitor behavioral outcomes for elderly patients under
opioids prescription so as to identify signs of addiction
beforehand and subsequently pursue interventional measures.
References
Dale, J. C., Hallas, D., & Spratling, R. (2019). Critiquing
Research Evidence for Use in Practice: Revisited. Journal of
Pediatric Health Care, 33(3), 342-346.
Ellis, P. (2019). Critiquing research: general points. Evidence-
based Practice in Nursing, 46.
LoBiondo-Wood, G., & Haber, J. (2017). Nursing research-E-
book: methods and critical appraisal for evidence-based
practice. Elsevier Health Sciences.
Shen, C., Zhao, X., Dwibedi, N., Wiener, R. C., Findley, P. A.,
& Sambamoorthi, U. (2018). Opioid use and the presence of
Alzheimer's disease and related dementias among elderly
Medicare beneficiaries diagnosed with chronic pain
conditions. Alzheimer's & Dementia: Translational Research &
Clinical Interventions, 4, 661-668.
Wang, H. T., Hill, A. D., Gomes, T., Pinto, R., Wijeysundera,
D. N., Scales, D. C., ... & Wunsch, H. (2020). Trends in opioid
use before critical illness among elderly patients in
Ontario. Journal of critical care, 55, 128-133.

Title of Project
Presenter Name
University name
Introduction and Problem
Variables
Descriptive Data
Results
Results (cont.)
Clinical Questions/PICOT
Discussion
Project Limitations
Conclusion and Recommendations
Purpose of the Project
The data analysis was in line with the needs of the project:
statistical tests, including t-test and Wilcoxon signed ranks,
were employed to determine if there were statistically
significant differences between pre- and post-test
measurements. This way, the relationships between the
independent and dependent variables were reliably inferred
(Polit & Beck, 2017)
Data types:
Survey: quantitative, ordinal (Likert scale).
Reports: quantitative, ratio (number of mistakes).
Data analysis approaches:
Software: SPSS.
Survey: Wilcoxon signed ranks test.
Reports: paired t-test.
Data Analysis
The project employed four Advanced Practice Registered
Nurses, three Medical Doctors, and one Physician Assistant who
exhibited significant resistance to the use of EHR.
References

.
.
Several studies have shown the benefits of the use of electronic
health records (EHR) for patients’ safety, as well as their ability
to improve efficiency in primary care settings (Porterfield,
Engelbert, & Coustasse, 2014). Regardless of the positive
effects of the implementation of EHR, health care providers
have moved slowly to adopt this technology (King, Patel,
Jamoom, & Furukawa, 2014). Practitioners who do not want to
adopt EHR, especially electronic prescription, can endanger
patient safety.
Medication errors, in turn, are a serious issue that causes
numerous safety incidents in primary care. Studies have shown
that the use of EHR significantly reduces the number of
prescription errors that can harm patients (Liao et al., 2017).
Palabindala, Pamarthy, and Jonnalagadda (2016) showed that
the use of EHR could reduce medication error while also
resulting in improved communications between patients and
healthcare teams
The purpose of this quantitative quasi-experimental project was
to determine if there was a relationship between the application
of an educational program and the improvement of
practitioners’ perception of EHR usability, as well as the
reduction of the number of prescription medication errors, at a
medical group practice in the Southeastern of the United States

(US).
The PICOT question created for the project was as follows: (P)
Among healthcare practitioners, (I) how does the
implementation of an educational program in a primary care
medical center in the Southeast of the US (C) compared to the
pre-intervention measurements in the prior four weeks (O)
influences primary care practitioners’ perceptions of the
usability of EHR and the incidence of prescription medication
errors (T) within four weeks of participating in the program?
The following clinical questions guide this quantitative project:
Q1: How does the implementation of an educational program
influence the perceptions of primary care practitioners
regarding EHR usability?
Q2: How does the implementation of an educational program
influence prescription medication error incidence?
Variable 1: Quality improvement educational program
(independent)
Variable 2: Primary care practitioners’ perception of EHR
usability (dependent)
Variable3: Number of prescription medication errors
(dependent).
The educational program can enhance the participants’
perceptions regarding EHR, but the described project cannot
reject the null hypothesis that the intervention had no effects on
the medication error rates. However, since the project was
constricted by significant limitations, this finding is not
conclusive.
Some of the research recommendations include the proposal to
increase the sample size, have a greater timeframe for future
projects, and consider randomizing the sample into two groups.
The project can also be used to recommend educational EHR
efforts for the reduction of EHR resistance and the specific
program that has been tested for the same purpose.

The sample was small (8 participants) and could not be
expanded because the facility was small.
The data collection process was limited by the short time
allocated to observing the results (4 weeks)
The project employed a quasi-experimental design. Since its
sample was so small, trying to split it further was not feasible.
King, J., Patel, V., Jamoom, E. W., & Furukawa, M. F. (2014).
Clinical benefits of electronic health record use: National
findings. Health Services Research, 49(1pt2), 392–404. doi:
10.1111/1475-6773.12135
Liao, T. V., Rabinovich, M., Abraham, P., Perez, S., DiPlotti,
C., Han, J., ... Honig, E. (2017). Evaluation of medication
errors with implementation of electronic health record
technology in the medical intensive care unit. Open Access
Journal of Clinical Trials, 9, 31-40. doi:
10.2147/OAJCT.S131211
Porterfield, A., Engelbert, K., & Coustasse, A. (2014).
Electronic prescribing: Improving the efficiency and accuracy
of prescribing in the ambulatory care setting. Perspectives in
Health Information Management, 2014, 1-13
Palabindala, V., Pamarthy, A., & Jonnalagadda, N. R. (2016).
Adoption of electronic health records and barriers. Journal of
Community Hospital Internal Medicine Perspectives, 6(5), 1-3.
doi: 10.3402/jchimp.v6.32643
Polit, D.F., & Beck, C.T. (2017). Nursing research: Generating
and assessing evidence for nursing practice (10th ed.).
Philadelphia, PA: Lippincott, Williams & Wilkins.
The survey contained 11 individual items and used a Likert
scale in which 1 stood for an extremely negative assessment of
an aspect of usability or usefulness and 5 referred to an

extremely positive one. The summary of the mean and standard
deviation for each of the items before and after the intervention
is presented in Table 1.
. The raw data indicate that the most common errors for the
clinic include incorrect dosage, incorrect drug, and drug-drug
interaction, as well as incorrect frequency and drug omission.
Table 4 presents the results of the paired t-test analysis of the
errors that occurred and those that were reported. No
statistically significant differences were found for either pair
(p>0.05). Thus, the findings do not suggest that the program had
an impact on medication error rates; a relationship between the
independent variable and medication errors was not found.
Example changes in pre- and post-test scores can be found in
Figure 4. Table 2 summarizes the results of analyzing the
survey items with the Wilcoxon signed ranks test. Items 1, 3, 4,
5, 6, 7, 8, 9, and 10 demonstrate statistically significant results
(p<=0.05).
Therefore, the intervention improved the perceptions of the
participants regarding the effect of EHR on one’s performance
and job effectiveness, the usefulness of EHR, the clarity of
interacting with the system, the ease of EHR use, and the use of
EHR for clinical care and research. The relationship between
the independent variable (program) and perceptions (one of the
dependent variables) was found.
Figure 1. The occupations of the participants.
Figure 2. Age of the participants.
Figure 3. Gender of the participants.
Figure 4. Example changes in survey results before and after the
intervention.
As had been planned, the data were collected before and after
the intervention using an already established survey tool and the
clinic’s pharmacy call reports regarding medication errors.

TEMPLATE DESIGN © 2008
www.PosterPresentations.com
1
Table 2
Survey Analysis Results Summary
Item Significance (1-tailed)
Q1 0.04
Q2 0.07
Q3 0.04
Q4 0.04
Q5 0.05
Q6 0.03
Q7 0.04
Q8 0.04
Q9 0.03
Q10 0.04
Q11 0.244
Table 1
Survey Summary
Item Pre-Test Post-Test
Mean St. Deviation Mean St. Deviation

Q1 2.25 0.707 4.75 0.463
Q2 2.13 0.991 4.38 0.744
Q3 1.75 0.707 4.38 0.744
Q4 2.25 0.707 4.75 0.463
Q5 2.13 0.991 5 0
Q6 1.63 0.744 4.75 0.463
Q7 2.38 0.744 4.38 0.518
Q8 2 0.756 4.13 0.641
Q9 2.25 0.886 5 0
Q10 1.63 0.518 5 0
Q11 4 0.756 4.38 0.518
Table 3
Error Data Summary
Error Type Number
Occurred
Number
Occurred
Number
Reported
Number
Reported
Incorrect Drug 3 4 3 4
Incorrect Dose 5 3 6 4
Incorrect Generic Selection 0 1 0 1
Outdated Product 0 0 0 0
Drug Unavailable/Omission 3 2 2 3
Incorrect Dosage Form 1 2 0 3
Incorrect Patient 3 3 2 4
Allergic Drug Reaction 1 0 1 0
Drug-drug Interaction 4 2 4 2
Incorrect time 1 2 1 2
Incorrect Route 1 2 1 2
Incorrect Frequency 3 3 4 3
Illegible or Ambiguous Prescription 3 0 4 0
Other 3 4 3 4

Total 31 28 31 32
Table 4
Total Errors Analysis Results: Paired Samples Test
Sig. (2-tailed)
Pair 1 .587
Pair 2 .846
Title of Project
Presenter Name
University name
Introduction and Problem
Variables
Descriptive Data
Results
Results (cont.)
Clinical Questions/PICOT
Discussion
Project Limitations
Conclusion and Recommendations
Purpose of the Project
Data Analysis
References
.

.
.
.
TEMPLATE DESIGN © 2008
www.PosterPresentations.com
1
Poster Presentation
Students this project will allow you to formulate and
hypothetically develop your own research project. The purpose
of this project is for the student to follow all of the different
steps in a research project on an already published article and
presented as a poster presentation. A poster session or poster
presentation is the presentation of research information by an
individual or representatives of research teams at a congress or
conference with an academic or professional focus. The work is
usually peer reviewed. Poster sessions are particularly
prominent at scientific conferences such as medical congresses.
Students will select a nursing research already published and

following the article information you will create a poster
presentation that include the below information:
The outline of the poster should include the following tabs
(minimum requirements)
Abstract Outline:
-Title of Project
-Problem Statement: what is the problem that needs fixing?
-Purpose of the Project
-Research Question(s)
-Hypothesis
-Methodology (Qualitative vs. Quantitative)
-Steps in implementing your project
-Limitations
Results (Pretend results)
-Conclusion
-References
I have attached an example of a poster presentation for
guidance. The due date for the poster presentation is WEEK 13.
Please feel free to be artistic and provide graphs and data. You
are welcome to use any poster template. Please submit it via
turn it in.
Criterion
Outstanding 4
Very Good 3
Good 2
Unacceptable 1
Score
Completeness
Complete in all respects; reflects all requirements
Complete in most respects; reflects most requirements
Incomplete many respects; reflects few requirements
Incomplete in most respects; does not reflect requirements
Understanding

Demonstrates excellent understanding of the topic(s) and
issue(s)
Demonstrates an accomplished understanding of the topic(s) and
issue(s)
Demonstrates an acceptable understanding of the topic(s) and
issue(s)
Demonstrates an inadequate understanding of the topic(s) and
issue(s)
Analysis
Presents an insightful and through analysis of the issue (s)
identified
Presents a thorough analysis of most of the issue(s) identified
Presents a superficial analysis of some of the issue(s) identified
Presents an incomplete analysis of the issue(s) identified.
Evaluation
Makes appropriate and powerful connections between the
issue(s) identified and the concept(s) studied
Makes appropriate connections between the issue(s) identified
and the concept(s) studied
Makes appropriate but somewhat vague connections between the
issue(s) identified and the concept(s) studied
Makes little or no connection between the issue(s) identified
and the concept(s) studied.
Opinion
Supports opinion with strong arguments and evidence; presents
a balanced and critical view; interpretation is both reasonable
and objective
Supports opinion with reasons and evidence; presents a fairly
balanced view; interpretation is both reasonable and objective
Supports opinion with limited reasons and evidence; presents a
somewhat one-sided argument
Supports opinion with few reasons and little evidence; argument

is one-sided and not objective.
Recommendations
Presents detailed, realistic, and appropriate recommendations
clearly supported by the information presented and concepts
studied
Presents specific, realistic and appropriate recommendation
supported by the information presented and the concepts studied
Presents realistic or appropriate recommendation supported by
the information presented and the concepts studied
Presents realistic or appropriate recommendation with little, if
any, support from the information and the concepts studied.
Grammar and Spelling
Minimal spelling and grammar errors
Some spelling and grammar errors
Noticeable spelling and grammar errors
Unacceptable number of spelling and grammar errors
APA guidelines
Uses APA guidelines accurately and consistently to cite sources
Uses APA guidelines with minor violations to cite sources
Reflects incomplete knowledge of APA guidelines
Does not use APA guidelines
Total

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